Costing the scale-up of voluntary medical male circumcision

The end of November saw the first in a series of nine new articles produced by researchers associated with the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the United States President’s Emergency Plan of AIDS Relief (PEPFAR).  This article proposes a rapid (five-year) scale-up of voluntary medical male circumcision (VMMC) in 13 priority sub-Saharan countries, and its maintenance through to 2025. The ensuing eight papers will focus on the various factors that go into effective program expansion of VMMC, including data for decision making, policy and programmatic frameworks, logistics, demand creation, human resources, and translating research into services.

The paper argues that VMMC should be a vital element in the HIV prevention toolbox in view of its proven effectiveness, low relative  cost and cultural acceptability: three randomised control trials have demonstrated a 57% protective effect for males against HIV; mathematical modelling has shown it is cost-effective, with costs to avert on HIV infection ranging from US$150 to US$900; it is also a widely accepted practice, with 67% sub-Saharan males already circumcised.

Maximum impact will require coverage of 80% across the 13 countries – a target which is very much more ambitious for some countries than for others, given the very different levels of circumcision constituting their point of departure.  The number of circumcisions needed to reach this coverage is estimated at 20.3 million.

The cost of scaling up VMMC over the years 2011-2015 in order to reach this figure is estimated at US$1.5 billion, and a further 0.5 billion is allowed for the maintenance of this coverage from 2015 through to 2025. Given discounted individual lifetime cost of antiretroviral therapy of US$7,400, net saving from 2011-2015 due to averted treatment and care cost would be US$16.5 billion.  The scale-up of VMMC would therefore be not only cost-effective but highly cost-saving.  It would “create fiscal space” that would otherwise have been encumbered by treatment costs.

If implemented, the scale-up would avert 3.4 million HIV infections.  The paper gives estimated percentages for proportion of infections averted for each of the 13 countries.  The figures vary from 9.2% for Swaziland to 41.7% for Zambia, with a million infections averted in South Africa alone.  Initial impact would largely be among men, but the proportion of infections averted in women steadily increases over time until 2025 when nearly half the infections averted would have been among women.

According to the authors, it is the need for accountable leadership and vision on the part of government leaders, and not access to funding, that poses the greatest challenge to the success of VMMC scale-up.  They draw particular attention to the challenge of mobilising human resources, and refer to the work of Curran et al. which reviews the concepts of task shifting and task sharing and describes approaches to expanding the health sector workforce through redeployment of personnel and use of expatriate volunteers (“Voluntary medical male circumcision: strategies for meeting the human resource needs of scale-up in southern and eastern Africa”). PLoS Medicine (November 2011) 8: e1001129).

Catherine Hankins et al., “Voluntary Medical Male Circumcision: An Introduction to the Cost, Impact, and Challenges of Accelerated Scaling Up”, PLoS Medicine (November 2011) 8 e1001127

Curran et al., “Voluntary medical male circumcision: strategies for meeting the human resource needs of scale-up in southern and eastern Africa”). PLoS Medicine (2011) 8: e1001129 doi: 10.1371/journal.pmed.1001129